Health Insurance Definitions
Co-Pay and Co-Insurance
Co-Pay: A fee you pay each time you receive healthcare. For instance, many insurance plans have a $15 or $25 fee each time you visit a doctor. Some plans don’t charge a co-pay for preventive care visits, like yearly check-ups. Usually, your co-pays don’t count toward your deductible or out-of-pocket maximum. At MWPH, your insurance may require you to pay two co-pays: one for the physician portion of your visit, and one for the hospital-related costs.
Co-insurance: Some plans require you to pay a portion of your costs, even if you have already met your deductible and already paid a co-pay. Co-insurance is usually a percentage of the total bill. For instance, if the co-insurance is 20%, your insurance will pay 80% of your medical bills and you will have to pay the other 20%. Once you hit your out-of-pocket maximum, you don’t have to pay the 20% anymore.
The amount you have to pay before insurance starts paying. For instance, if you have a deductible of $2,000, you will have to pay for most or all of your healthcare expenses until you have spent $2,000. (Some policies will pay for a few services, like preventive care, before you have met your deductible.)
EOB - Explanation of Benefits
An EOB is a document from your insurance plan that shows what you were charged, what your insurance has paid, and what you will have to pay.
In-Network: This is your insurance company’s approved list of doctors or providers. If you use an in-network provider, your costs will usually be lower.
Out-of-Network: These are doctors or providers that aren’t on your insurance company’s approved list. If you use an out-of-network provider, your costs will usually be higher.
Carve-Out: These are services that are not covered by your insurance at a specific place, even if the place is in-network. For instance, your policy might cover most services at Mt. Washington Pediatric Hospital, but might require you to go elsewhere for services like psychology, rehabilitation or lab tests. In this case, your services here would not be covered by insurance, even though MWPH is in-network.
This is the most you’ll pay toward your healthcare in a given year. If your insurance plan has an out-of-pocket maximum of $5,000, once you’ve paid $5,000, the insurance company picks up (most of) the rest of the costs in that plan year. There might be some costs you still have to pay, such as co-pays or non-covered services.
Outpatient Hospital Visit Fees: Professional Fee and Facility Fee
At MWPH you will be charged two different fees each time you come to see a doctor or nurse practitioner.
The professional fee covers the services you receive from the provider who sees your child.
The facility fee covers the costs of nurses or other staff who help during your visit. It also covers the cost of overhead expenses like heat, electricity, etc. The state of Maryland requires MWPH to charge for these facility fees in addition to the professional fee.
The amount you pay each month for your health insurance plan.
Typically includes yearly checkups, screenings, or immunizations. As a result of the Affordable Care Act (Obamacare), preventive care is 100% paid for under most insurance plans and you will probably not have to pay co-pays.
Rehabilitation – PT, OT or Speech services to help a patient regain abilities that they lost due to an accident or illness. This can include Physical Therapy to help a patient learn to walk again after a car accident.
Habilitation – PT, OT or Speech services to help a patient gain abilities that they never had. This can include helping a child learn to speak for the first time.
Coverage - Some insurance policies have different coverage rules, depending on whether the therapy services involve Rehabilitation or Habilitation services. Some insurance policies may cover one type of care, but not the other.